How good is Queensland?

The new Queensland pharmacist prescribing trial is seen by many as a way to move Australian pharmacists away from winning the global “wooden spoon” for scope of practice. Megan Haggan reports

All eyes are turning to Queensland after its State Government recommended, in response to the Inquiry into the Establishment of a Pharmacy Council and Transfer of Pharmacy Ownership in Queensland, that a pilot project look at limited pharmacist prescribing.

“Extending the scope of practice for pharmacists and pharmacy assistants” was one of the four key issues on which the review focused, though pharmacy stakeholders in Australia and internationally prefer to talk about pharmacists being enable to practise at the full scope of their expertise, or fulfilment of practise.

The Committee’s Recommendation 2 was that the state’s Department of Health “develop options to provide low-risk emergency and repeat prescriptions (for example, repeats of the contraceptive pill) and low-risk vaccinations (including low-risk travel vaccinations) through pharmacies subject to a risk-minimisation framework”.

It suggested several ways this framework could look, including:

consultation with a GP utilising 13HEALTH;

limitations on the number of times a prescription can be issued within a period of time (for example, only once in a six-month period);

on-site testing; and

a requirement that the pharmacist consult a 13HEALTH GP or have regard to the patient’s medical record via MyHealthRecord.

“Any change in pharmacists’ scope of practice should be underpinned by appropriate credentialing and training for the services to be delivered,” the review recommended.

The Government accepted this recommendation in principle, saying that it would wait until the Australian Health Protection Principal Committee (AHPPC) working group had established its options on further low-risk vaccinations (including low-risk travel vaccinations). But in the meantime, it would “develop, implement and evaluate a state-wide trial to provide low-risk emergency and repeat prescriptions for the contraceptive pill and antibiotics for urinary tract infections.”

To support the recommendation, Queensland Health is evaluating and reviewing proven models from similar health systems for relevance to Queensland, and/or trial new models of care and determine training and governance, the Government said; it is also establishing a multidisciplinary group to consider the outcomes of the AHPPC working group, and if necessary, develop further options, in accordance with the recommendation.

The reaction

While condemnation from the Royal Australian College of General Practitioners and the Australian Medical Association was swift and severe, the Pharmacy Guild of Australia and the Pharmaceutical Society of Australia warmly welcomed the move.

Anecdotally, so did patients.

Meanwhile in Western Australia, a Review of Community Pharmacy Ownership in the state was carried out, and also looked at scope of practice.

Recommendation 9 stated that the state Government acknowledged a potential underutilisation of pharmacies and pharmacists, while Recommendation 11 said that “Western Australia should closely monitor national developments and discussions relating to non-medical prescribing for pharmacists…” such as the Queensland pilot.

Stakeholder branches such as the PSA and Guild in NSW continue to lobby for a similar trial to Queensland’s – though the state Health Minister, Brad Hazzard, rejected a call by these bodies as well as the NSW Opposition to implement a similar trial in that state.

And at the National Party’s 2019 conference in Inverell, NSW, a motion put forward by NSW Guild branch committee member Judy Plunkett saw enabling pharmacists to prescribe trimethoprim for acute UTIs become official Nationals policy.

Speaking from Western Australia where he was attending a Pharmacy Guild forum, Mr Twomey said that the interest from WA in the Queensland trial was very high.

He and PSA Queensland state branch president Chris Campbell praised the Queensland Government and its Health Department for their collaboration with pharmacy.

“I’ve had the pleasure of spending some time with the [WA] Deputy Premier and Roger Cook, the Health Minister, and he loves his local pharmacy,” Mr Twomey said. “I don’t think WA is any different to Queensland in that regard: they have the highest level of respect and trust for pharmacy, and they value the highly-skilled and highly-trained staff, and the convenience that accessing a greater level of service from pharmacy brings.”

Guild Queensland Branch president Trent Twomey: “How good is Queensland?”

Chris Campbell said that the discussion about scope fulfilment was bringing up similar scenarios to the introduction of pharmacist vaccination, which also got off to its Australian start in Queensland, through the award-winning Queensland Pharmacist Immunisation Pilot of 2014. QPIP’s first phase saw pharmacist flu vaccination successfully introduced, followed by a second phase which included measles and whooping cough vaccinations for adults, as well as the 2015 flu vaccination.

He said that while administering medicines was, in 2014 and beforehand, listed in pharmacists’ scope of practise, at the time of the trial he could “look at my peers and see that nobody is doing that” when it came to vaccines.

“Now, if I’m a student coming into a pharmacy, I’ll see my pharmacist administer vaccines, and that’s normalised,” he said.

In a few years, pharmacist prescribing of antibiotics for UTIs, and repeats for the oral contraceptive pill, will likely be similarly commonplace, he said.

Backlash

Perhaps predictably, the doctor groups reacted to the news of the pharmacy pilot with anger and dismay – to the point where at the AMA’s Annual General Meeting in May 2019, Dr Bav Manoharan, director at the AMA and its Queensland branch, moved “That Federal Council and AMA Federal President call for an urgent and immediate end to the trial of prescribing of antibiotics, paediatric vaccinations and oral contraceptives by community pharmacists in Queensland and Nationally, and to call for the Queensland Health Minister to adhere to national processes as occurring under the direction of COAG”.

The motion was passed. Meanwhile the RACGP sent a letter to all Queensland MPs in a bid to halt the trial.

A number of prominent doctors also complained that they felt the trial – and pharmacist prescribing of antibiotics in general, though the conversation around UTIs centres around trimethoprim – would leave non-UTI conditions such as an STI undiagnosed; many of their concerns were around potential for the rise of “superbugs”.

“Introducing more and less experienced prescribers will only exacerbate the current challenges we have with overprescribing,” said Dr Bruce Willett, Queensland Chair of the RACGP.

The RACGP’s Dr Harry Nespolon warned of the rise of ‘superbugs’ with pharmacist prescribing.

The RACGP’s national president, Dr Harry Nespolon, said that “the Queensland Government is thumbing its nose at antibiotic stewardship. Even the World Health Organisation sees this as a major health problem. Governments should be trying to decrease the number of prescribers of antibiotics not flippantly increase them.

“When you have a pharmacist dispensing and prescribing rights you remove all of the needed checks and balances on medications, leaving the system open for increased human error or worse, risk of manipulation for business purposes. Ultimately, it is the patient who suffers.”

Mr Twomey told the AJP that the Pharmacy Guild, and pharmacists more widely, are very aware of and cautious about antimicrobial resistance.

“It is a real thing,” he said. “It needs to be addressed. And what we’re saying is: Look to the evidence.”

International evidence

Both Mr Campbell and Mr Twomey highlighted that international evidence showed that pharmacists were more likely than GPs to stick to protocols around the supply of antibiotics.

“If you look at similar scenarios, such as in Canada where they do have protocol-driven prescribing, pharmacists demonstrated better adherence to protocol,” Mr Campbell said. “We want to look at the international evidence where this has occurred, and ensure better, or at least no worse, use of protocol – particularly around antimicrobial resistance. That is a clear tenet of the pilot.”

Christine Hrudka told APP 2019 that “Pharmacists do a damn good job.”

For example, a 2018 study published in the Canadian Pharmacists’ Journal showed that pharmacists were better at following the prescribing algorithms for acute non-complicated UTIs than doctors.

Christine Hrudka, chair of the Canadian Pharmacists’ Association, cited this study at the Australian Pharmacy Professional Conference on the Gold Coast earlier this year, telling delegates that “Pharmacists do a damn good job.”

“The whole group of ‘we’re going to have antibiotic resistance rampant because pharmacists can just at will prescribe?’ That did not come out in the study. We did a better job of following the correct algorithms,” she told the conference at the time.

And it’s important to remember that pharmacist prescribing of items like the oral contraceptive pill and antibiotics for acute UTIs are not the same as a simple downschedule, Mr Campbell said… so these medicines would not be handled even in the manner of an S3.

“We haven’t had Appendix M tested… and so the difference between this and straight-out downscheduling is the need to ensure that it is delivered via a structured protocol, and requirements that are lifting the standards of pharmacist care,” he said.

“There will be professional practice standards discussed – for example, the need for a private consultation area to offer these services. Those are becoming increasingly commonplace, especially in Queensland.

“It’s around the continuum of complexity, or of risk, that a medicine would have. So as you move from S2 to S3, then you’ve got continued dispense items in S4, the risk and complexity increases, and so should the process and protocol of the process that follows them.”

He said that under the Queensland protocols – though the details of these have not yet been released – pharmacists would never prescribe in isolation.

“A decision is made as part of the health care team, as opposed to taking that role from someone else,” Mr Campbell said. “We want to ensure people have access to the care they need, and not be prohibited from that because the legislation hasn’t caught up with the competencies and scope of the profession.”

The benefits

“Queensland Health are supportive of all professions practising to fulfilment of scope,” Mr Campbell told the AJP.

“It’s not just pharmacists. It’s physios, it’s podiatrists, it’s GPs.

“They know that by doing that you’re improving access – so for example, when a GP is doing more of the heavy lifting in a speciality area, such as diabetes, instead of having that patient always see an endocrinologist, you’re empowering that GP to take on more, do more in that area and free up the specialist.”

He said that Queensland was a particularly good example of a jurisdiction where better access could help, due to its large geographical spread.

The Pharmacy Guild’s Matthew Tweedie, in response to doctor comments made following the WA Government’s release of the WA pharmacy review, had made similar comments, pointing out that “There are 40-odd towns in rural and remote areas [of Western Australia] with no general practice, or towns where people have to travel a long way to get to it.”

However Trent Twomey also pointed out that people living in urban and suburban areas would also benefit significantly from increased access to the Pill and to antibiotics for acute UTIs.

“We’re medically underserviced – you could be in the middle of the metro area and on certain days of the week, have issues gaining access to a GP,” he said. “This happens in Fortitude Valley, not just in Far North Queensland.

“What I think we will find is that there are increasing pressures on state and territory health budgets – and at the same time, an increasing expectation from Australians to be able to have, and retain, access to the best health care,” Mr Twomey said.

“The only way we can do this as a community is if all players in health care are practicing to full scope: pharmacists, GPs and nurses alike.

“Australians have always been very proud of our universal health care scheme. We don’t look to the US and think that their two-tiered health care system, with the haves and have-nots treated differently, is something that we want to see in Australia.

“But likewise we look to the UK and the European Union, and see that we can’t afford to have that level of spending either.”

Health professionals practising to their full scope is a clear answer, he said.

“It makes sure that we remain at the head of the curve – that we move from winning the wooden spoon globally in terms of scope of practice, to winning the gold medal.”

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